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SYNCHRONICITYUPDATE

SEPTEMBER 2015

Upcoming enhancements coming to the EHR in response to ICD10and Meaningful Use

TABLE OF CONTENTS

Table of Contents

Upcoming Enhancements________________________________________________________________________________ 1

ICD-10 _____________________________________________________________________________________________________ 3

ICD-10 Overview___________________________________________________________________________________________________ 3

STRUCTURAL DIFFERENCES BETWEEN ICD-9-CM AND ICD-10-CM/PCS ____________________________________ 3

Why Transition to ICD-10 _________________________________________________________________________________________ 3

Compliance Date ___________________________________________________________________________________________________ 4

ICD-10 Resources __________________________________________________________________________________________________ 4

Diagnosis Assist____________________________________________________________________________________________________ 5

Patient Workflow _________________________________________________________________________________________ 6

Electronic Professional Billing (E&M and Procedure Codes) _________________________________________ 7

What will be billed electronically?________________________________________________________________________________ 7

When will this change occur ______________________________________________________________________________________ 7

what are the benefits of electronic billing _______________________________________________________________________ 7

What Do I need to Know __________________________________________________________________________________________ 7

How do I reconcile my billing _____________________________________________________________________________________ 7

Charge Correction Process _______________________________________________________________________________________11

Credit a Charge_________________________________________________________________________________________________11

Other Corrections ______________________________________________________________________________________________12

Medication Reconciliation _____________________________________________________________________________ 14

My role in Medication Reconciliation ___________________________________________________________________________14

Clinical Decision Support Rules _______________________________________________________________________ 15

Health Maintenance ____________________________________________________________________________________ 16

Health Maintenance Workflow __________________________________________________________________________________16

Beginning October 1st, the Influenza Vaccine and the Adult or Child Wellness Visit will be documented

within Health Maintenance.______________________________________________________________________________________16

Documenting Influenza Vaccine _________________________________________________________________________________16

If the patient receives the Influenza vaccine in one of our clinics, this Health Maintenance will be satisfied

when the nurse documents the influenza vaccine. If the patient received the vaccine outside of our

TABLE OF CONTENTS

organization, it will need to be documented under the Immunization Schedule History and this will satisfy

the measure. In addition it the Influenza vaccine, the Adult and Child Wellness visits should be

documented for Health Maintenance. ___________________________________________________________________________16

Documenting Influenza vacinnes done elsewhere _____________________________________________________________16

DOCUMENTING WELLNESS EXAMS_____________________________________________________________________________18

Documenting Wellness exams done elsewhere_________________________________________________________________18

Electronic Patient Reminders _________________________________________________________________________ 20

External Referral Orders (Transition of Care)________________________________________________________ 21

Transition of Care Process _______________________________________________________________________________________21

Immunizations__________________________________________________________________________________________ 28

Real-time grits upload____________________________________________________________________________________________28

Immunization Schedule—CHANGES ____________________________________________________________________________28

Patient Portal Secure Messaging and Refill Requests________________________________________________ 29

Management of Pools_____________________________________________________________________________________________29

UPCOMING SYNCHRONICITY ENHANCEMENTS

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Upcoming Enhancements

A. ICD10

B. ELECTRONIC PROFESSIONAL BILLING (E&M AND PROCEDURE CODES)

Physician professional charges and Practice Site technical charges will be captured electronically.

We will begin piloting Ambulatory Professional e-Billing on Sep. 9. for:

1. Internal Medicine2. General Pediatrics3. Pediatric Surgery4. Plastics5. Dermatology6. Podiatry (Dr. Szabo)7. Neurology (Dr. Pruitt)

All other ambulatory sites will go-live with Professional e-Billing on Sep. 15. Additionally, all new featuresrelating to Meaningful Use will now go-live on Sep. 15.

C. MEDICATION RECONCILIATION

All patient encounters where they are seen by a physician will require that Medication Reconciliation be

completed. There will be a hard stop within Synchronicity that will prevent a physician from being able

to place a Return to Clinic Order or a professional billing order before Medication Reconciliation is

completed.

It is very important that a detailed Medication History is documented during the patient Intake process.

Before the physician is able to complete the patient’s Medication Reconciliation, a Medication History

must be documented. A completed Medication History can be identified under the Reconciliation Status

located at the top right corner of the medication screen. There will be a green checkmark in front of Meds

History .

D. PATIENT PORTAL

1. Secure Messaging

2. Refill Requests

3. Appointment Request

E. CLINICAL DECISION SUPPORT RULES

A. Clinical Efficiency - If 2 different providers place the same lab order within 3 days of each other the

nurse activating the 2nd order will receive this alert. At that time they will have the option to Order

Anyway or Remove the duplicate order.

B. Smoking Status - Once the Smoking status is documented in Social History, the Tobacco User

problem is added to the Problem List

C. Med Rec Rule – Must be complete before placing professional charges and before placing Return to

Clinic Order


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D. Health Maintenance – The two Health Maintenance measures that are currently being monitored

are the Adult and Child Wellness visits and the Influenza Vaccine.

F. EXTERNAL REFERRAL ORDERS (TRANSITION OF CARE)Each physician who transitions their patient to another setting of care or provider of care or refers their

patient to another provider of care outside of our organization should provide summary care record for

each transition of care or referral.

G. IMMUNIZATIONSImmunizations will now be transmitted to GRITS in real time. This will allow staff to print off a current

listing of the patient’s immunizations at the end of the clinic visit.

H. HEALTH MAINTENANCEMeaningful Use stage 2 requires physicians to be able to use clinically relevant information to identify

patients who should receive reminders for preventive/follow-up care and send these patients the

reminders, per patient preference. The Health Maintenance module will allow us to fulfill this

requirement.

I. ELECTRONIC PATIENT REMINDERSBased on data collected during intake and the physician’s documentation, Health Maintenance satisfiers

will be marked as met for the Influenza Vaccine and the Well Adult and Child Visit.


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ICD-10

What is ICD-10?

In 1990, the World Health Organization (WHO) approved the 10th Revision of the International Classification

of Diseases (ICD), known as ICD-10.

ICD-10 OVERVIEW

A. ICD-10 replaces the ICD-9 code sets and includes updated medical terminology and classification of

diseases:

B. ICD-10 CM/PCS consists of two parts:

ICD-10-CM for diagnosis coding in all health care settings

ICD-10-PCS for inpatient procedure coding in hospital settings

C. CPT coding for outpatient and office procedures is not affected by the ICD-10 transition

D. ICD-10-CM replaces ICD-9-CM for diagnosis coding:

ICD-9-CM diagnosis codes = 3 to 5 digits

ICD-10-CM codes = 3 to 7 digits

Overall format of ICD-10 diagnosis codes similar to ICD-9

STRUCTURAL DIFFERENCES BETWEEN ICD-9-CM AND ICD-10-CM/PCS

A. ICD-9-CM Procedure Codes:

3–4 digits;

i. All digits are numeric; and

ii. Decimal is after second digit.

Examples:

i. 43.5 – Partial gastrectomy with anastomosis to esophagus; and

ii. 44.42 – Suture of duodenal ulcer site.

B. ICD-10-PCS Procedure Codes:

7 digits;

Each digit is either alpha or numeric (alpha digits are not case sensitive and letters O and I

are not used to avoid confusion with numbers 0 and 1); and

No decimal.

Examples:

i. 0FB03ZX – Excision of liver, percutaneous approach, diagnostic; and

ii. 0DQ10ZZ – Repair upper esophagus, open approach.

WHY TRANSITION TO ICD-10

A. Better reflects current medical practice

B. Captures more specific data from clinical documentation than ICD-9

ICD-10-CM: For fractures, for example, captures left vs. right side of body, initial vs.

subsequent encounter, routine vs. delayed healing, and nonunion vs. malunion

ICD-10-PCS: Provides detailed information on procedures and distinct codes for all types of

devices

C. Detail captured by ICD-10 can:


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Facilitate patient care coordination across setting

Improve public health reporting and tracking

D. ICD-10 structure accommodates new codes

ICD-9 is running out of capacity and cannot continue to accommodate addition of codes to

reflect new diagnoses and procedures

COMPLIANCE DATE

A. By October 1, 2015, we must start using ICD-10 codes for services provided on or after October 1,

2015

ICD-10 RESOURCES

A. CMS website:

www.cms.gov/icd10

Features fact sheets, FAQs, and implementation guides, timelines, and checklists

B. CMS ICD-10 Email Updates provide timely information

To sign up for updates:

Go to www.cms.gov/icd10

Select “CMS ICD-10

i. Industry Email Updates” from left navigation bar

Click on “Sign up for update messages”

C. Fact sheets on ICD-10 for providers, payers, and vendors

Available on the Provider, Payer, and Vendor Resources pages of the CMS website

D. Online ICD-10 Guide: on Provider Resources page, www.cms.gov/ICD10

Step-by-step ICD-10 advice for clinical practices


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DIAGNOSIS ASSIST

To help the physician choose the most specific diagnosis possible, Synchronicity provides the Diagnosis Assist

tool. When a diagnosis is searched and chosen, if it has the required specificity to be able to be used for

billing, it will show on the Diagnosis List with a bulls-eye. The physician can use the Diagnosis Assist tool by

clicking on the bulls-eye to determine the most specific diagnosis code.


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Patient Workflow


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Electronic Professional Billing (E&M and Procedure Codes)

WHAT WILL BE BILLED ELECTRONICALLY?

• E/M Billing and Procedure Codes

• Routing of Codes electronically to IDX

• Reconciling Codes in IDX

WHEN WILL THIS CHANGE OCCUR

We will begin piloting Ambulatory Professional e-Billing on Sep. 9. for:

8. Internal Medicine9. General Pediatrics10. Pediatric Surgery11. Plastics12. Dermatology13. Podiatry (Dr. Szabo)14. Neurology (Dr. Pruitt)

All other ambulatory sites will go-live with Professional e-Billing on Sep. 15. Additionally, all new featuresrelating to Meaningful Use will now go-live on Sep. 15.

WHAT ARE THE BENEFITS OF ELECTRONIC BILLING

• The workflow will remove the need for manual handling/batching of the claims.

• Charges will be captured at the point they are incurred

• Reduction in errors

WHAT DO I NEED TO KNOW

• To prevent duplicate charges, clinic staff should ONLY enter the leveling charge for each encounter.

All other charges should be captured when

o Physicians enter their orders

o Clinical staff complete orders written by physicians

o Clinical staff mark appropriate task as completes

HOW DO I RECONCILE MY BILLING

In order to ensure charges are being entered daily to provider encounters, Practice Sites should complete a

reconciliation process daily. Instructions to complete this process follows:

1. Sign into Citrix


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2. Choose Explorer Menu P461

3. Choose Main Menu and click + to open AMBU Reports


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4. Click on Ambulatory Daily Recon Detail Report

5. Choose the encounter date and service that you wish to open


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6. Click Execute button on bottom right of screen to open the report.

This will open a list of arrived patients with associated charges attached for the appropriate date and

service.

Each encounter needs to be checked for the following:

a. Diagnosis code

b. Nursing Outpt service charge (unless patient only seen for procedure)

c. Office/Outpt visit (unless patient only seen for procedure or nurse visit only)

d. Any associated procedural charges including nurse only procedures

7. If there are any professional or facility charges that are missing, print the report and notate the

missing charges.

8. Nursing will enter any missing technical charges, by the close of business, where the encounter has a

diagnosis code available to attach to the charge.

9. **IMPORTANT – Charges for patients that have been admitted to the hospital will not show up

on the report.

10. File the report and use it to reconcile any missing charges on the next business day. Any remaining

charges that are missing need to be reported to the Nurse Coordinator/Manager, Administrative

Director, and the Medical Director of the Practice Site. It will be the responsibility of leadership to

contact the physician for charge entry.


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11. Late charges entered will be noted on the report with the date of entry.

12. Daily Report will be submitted by each Practice Site to the VP Ambulatory Care Services, Medical

Director of Ambulatory Care Services, Director of Ambulatory Nursing, Practice Site Medical Director,

the Practice Site Admin Director/Manager, and the Administrative Assistant to the VP of Ambulatory

Care Services indicating those with outstanding charges.

13. Reports will be kept on file and checked each morning until all charges have been placed for that Date

of Service. The completed report should then be provided to the Nurse Coordinator/Manager or

Administrative Director as designated.

CHARGE CORRECTION PROCESS

Credit a Charge

Crediting a charge means the credit quantity matches the original debit quantity for all charges or a change in

quantity to be less than original quantity (partial credit) for non-interval charges. Charge viewer cannot be

used to credit back more the quantity that originally posted for the charge. Where possible, users should

update the documentation that created the charge rather than just crediting through charge viewer, as that

will maintain a better audit trail because the clinical documentation matches the charges For example if a user

documents 4 units of therapy time with a client, then if they modify the form to 2 units of therapy time,

charges created from that documentation will be credited and new debits created with the appropriate

quantity.

The credit function can be accessed by either an icon on the toolbar or by right-clicking a charge and select

Credit Charge from the context menu. A Credit Charge dialog box opens, which includes the following

information:

1. Person name

2. FIN

3. Charge description

4. Quantity

5. Item price

6. Extended price

7. Reason

8. Reason note

If the quantity of the original debit charge is 1 (one) only the reason and reason note fields will be active.

If the quantity of the original debit charge is greater than 1 (one), the quantity, reason, and reason note fields

will be active.

The Credit Charge icon enables the selected bill items to be credited if the charge status is in one of the

following states:

• Pending

• Review

• On Hold

• Interfaced

• Posted

• Combined


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When the Credit Charge button is clicked, the following window is displayed:

To complete the credit process, follow the steps below:

1. Select the bill item or items to be credited. Verify that the status column indicates the charge is

Pending, Review, On Hold, Interfaced, Posted, or Combined.

2. Click the Credit Charge button on the tool bar.

3. Select a reason for crediting the item from the Reason list - the reason is the general category for the

credit

4. If applicable, enter a note documenting in detail the reason the item was credited.

5. Click OK to credit the charge. The following message is displayed:

1. Click Yes to complete the credit process. The following message is displayed, indicating that the

charge was successfully credited.

Once credited, both the debit and credit will display in red in the charges spreadsheet. The credit will be

displayed below the original charge when the user clicks the original charge.

Other Correc�ons

Desk-op Team Leads will send daily emails out from charges suspended from the following edits that take

place.

1. Duplicate Evaluation and Management Charges on encounter


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2. MisMatch Arrival Dates Vs. Charge Dates

3. Ambulatory Charges on Inpatients

4. Technical Charges missing a CDM

5. Charges placed on wrong encounter/location

6. Late charge where the account had already bill, The HealthQuest system auto reverses the charge

from the account, which means this charge did not post.


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Medication Reconciliation

Beginning September 9, 2015, Medication Reconciliation becomes a requirement on 100% of all ambulatory

evaluation and management encounters. The system has a hard stop that will prevent the physician from

placing a

• Return to Clinic Order or

• A professional order

until the Medication Reconciliation is completed.

MY ROLE IN MEDICATION RECONCILIATION

It is vital that clinical support staff in each clinic complete the Document Medication by Hx during the intake

process. Patient safety depends on careful attention to this process. The Medication History MUST be

completed prior to the physician seeing the patient so that the physician can complete the required

Medication Reconciliation.

To facilitate the most accurate and complete Medication Reconciliation, clinical staff should

A. “Complete” all medications the patient states they are no longer taking because it has been

discontinued or they completed.

B. Document compliance for any medication patient still should be taking but stated they have stopped.

C. Document compliance on any medication the patient states they are taking differently than

prescribed.

D. If necessary, use the External Rx History to ensure you have the most accurate medication history.


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Clinical Decision Support Rules

This is functionality that builds upon the foundation of an EHR to provide persons involved in care processes

with general and person-specific information, intelligently filtered and organized, at appropriate times, to

enhance health and health care.

The following are Clinical Decision Support Rules that will go-live September 15, 2015.

A. Clinical Efficiency - If two different providers place the same lab order within 3 days of each other

the nurse activating the 2nd order will receive this alert. At that time they will have the option to

Order Anyway or Remove the duplicate order.

B. Smoking Status - Once the Smoking status is documented in Social History, the Tobacco User

problem is added to the Problem List

C. Med Rec Rule – Must be complete before placing professional charges and before placing Return to

Clinic Order

D. Health Maintenance – Beginning October 1st, must document on the Health Maintenance tab if the

patient has had the Influenza vaccine. If the patient receives the Influenza vaccine in one of our

clinics, this Health Maintenance will be satisfied when the nurse documents the influenza vaccine. If

the patient received the vaccine outside of our organization, it needs to be documented under the

Immunization Schedule History and this will satisfy the measure. In addition it the Influenza

vaccine, the Adult and Child Wellness visits should be documented for Health Maintenance.


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Health Maintenance

Meaningful Use stage 2 requires physicians to be able to use clinically relevant information to identify patients

who should receive reminders for preventive/follow-up care and send these patients the reminders, per

patient preference. The Health Maintenance module will allow us to fulfill this requirement.

HEALTH MAINTENANCE WORKFLOW

Beginning October 1st, the Influenza Vaccine and the Adult or Child Wellness Visit will be documented withinHealth Maintenance.

DOCUMENTING INFLUENZA VACCINE

If the patient receives the Influenza vaccine in one of our clinics, this Health Maintenance will be satisfiedwhen the nurse documents the influenza vaccine. If the patient received the vaccine outside of ourorganization, it will need to be documented under the Immunization Schedule History and this will satisfy themeasure. In addition it the Influenza vaccine, the Adult and Child Wellness visits should be documented forHealth Maintenance.

DOCUMENTING INFLUENZA VACINNES DONE ELSEWHERE

From the Health Maintenance tab

Find the Influenza Vaccine


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If the patient reports they have already had their flu vaccine (or any other vaccine) and it

shows it as still needed, document the immunization from the Immunization Schedule tab

. Once documented as a historical vaccine, the expectation in health

maintenance will be satisfied.


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DOCUMENTING WELLNESS EXAMS

When the physician sees a patient and bills for the appropriate wellness exam, the Wellness Exam measure on

the Health Maintenance screen will become met.

DOCUMENTING WELLNESS EXAMS DONE ELSEWHERE

If the patient’s primary care physician is outside GRHealth, the measure will need to be manually met. This

can be accomplished by taking the following steps:

1. Go to the Health Maintenance tab

2. Under the Wellness Exam (Adult or Child), choose the appropriate satisfier. For those having their

wellness exam outside of our organization, the choice would be Exam Done Elsewhere.

3. When the pop-up screen appears, fill-in the appropriate information and press OK.


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4. This will then satisfy the measure and place it under the Recently Satisfied Expectations and move the

due date to the next scheduled time due under Pending Expectations.


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Electronic Patient Reminders

Based on data collected during intake and the physician’s documentation, Health Maintenance satisfiers will

be marked as met for the Influenza Vaccine and the Well Adult and Child Visit. At certain defined intervals,

patient reminders will be sent to patients who do not show these Health Maintenance items as satisfied. The

reminders will be sent to the patient’s portal or mailed to the address on file reminding them of the need to

satisfy these reminders.


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External Referral Orders (Transition of Care)

Each physician who transitions their patient to another setting of care or provider of care or refers their

patient to another provider of care outside of our organization should provide summary care record for each

transition of care or referral.

For patients meeting this criteria, the Desk-op will need to complete the Transition of Care process before the

patient checkout process is completed.

TRANSITION OF CARE PROCESS

1. The physician will place an External Referral/Consult Order on the correct visit

2. The Order will go to the Task List and the Multi-patient Task List

3. Clinic Staff selects depart from within the patient’s chart and select the follow up date:

4. Search for the provider in the Provider search field:


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5. If the provider is listed, select provider and then select ok:

6. The provider appears at the bottom of the screen:

7. If the provider IS NOT listed in the Provider Search, select Free- text follow-up and type in the provider’s

name and select add.


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8. Type provider’s name in the External recipient’s email and select binoculars to search

9. Select the correct physician and select ok, the secure email will now populate in the external recipient

address field:


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10. Once selected the screen will appear as follows:

11. If the provider appears in the external recipient email field, nothing else needs to be done. If the

provider does not appear, please proceed as instructed below.

12. If the provider is not found within the Provider search field, nor the external recipient email field, please

use the provider Letter functionality to print the Transition of Care summary to give to the patient. Open

the appropriate patient encounter and from the toolbar, choose Communicate, then Provider letter:

13. Select External from the drop down and type in provider’s name:

14. Select provider by double clicking on name:


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15. If the mode defaults to fax, select mode field and select mail from the drop down:

16. Unselect the Forward to print field at the bottom of the screen and select ok at the bottom, right hand

corner of the screen:

17. When the following screen appears, select the Transition of Care Field:

18. This screen appears. Make sure the Referral order place by the provider for this external provider is

selected and select continue:


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19. The Transition of Care document will attach to the letter (this may take a few seconds):

20. Select Ok and a print prompt will appear. Make sure you select the correct printer if it does not default:


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21. Give the printed Transition of Care to the patient. The provider letter now appears within the Clinical

Notes.


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Immunizations

REAL-TIME GRITS UPLOAD

Immunizations will now be transmitted to GRITS in real time. This will allow staff to print off a current listing

of the patient’s immunizations at the end of the clinic visit.

IMMUNIZATION SCHEDULE—CHANGES

A. Adding Palivizumab Inj

B. Adding the HPV9 - abbreviation 9vHPV

C. Add Poliovirus vaccine, live oral --abbreviation OPV

D. Add hepatitis B immune globulin – abbreviation HBIG

E. Add Meningococcal B Vaccine – abbreviation OMV

F. Change the “Do Not Use” and “No Longer Available”

to – “For Historical Documentation Only”


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Patient Portal Secure Messaging and Refill Requests

As part of Meaningful Use Stage 2, providers are required to use secure electronic messaging to communicate

with patients on relevant health information. Patients will now have the ability to communicate with their

providers through the V.I.P. Patient Portal. These messages will go to designated pools based on each

provider’s service. Each pool will be monitored by assigned staff.

Patient will have the ability to send messages for the following:

1. General questions

2. Requests for medication refills

3. Request for an appointment

MANAGEMENT OF POOLS

Individuals will be assigned to manage pools based on Service and the

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